Self-Assessment Forms

To help you, we have created the following brief addiction self-assessment questionnaires. Choose the questionnaire or questionnaires that apply to you and your situation the most closely. Write the answers down on separate paper, we urge you to commit pencil to paper. There is something about physically writing emotionally charged feelings down that makes it more real. I also find that many people act more quickly when they have written down and “made a list.”

Once you have a better idea of whether you are ready for help, what next? Call Us…Email Us. (800) 929-5904. Contact Us.

Food + Weight

1. Do you tend to experience dramatic weight loss or weight gain? If yes, how is this affecting you?

2. Do you wear baggy clothes or layer clothes, hoping to disguise weight loss or gain? If yes, how does this make you feel?

3. Are you obsessed with exercise (for example, always wanting to exercise after eating)? If yes, how is this affecting you?

4. Do you complain about being overweight, even though you are very thin? If yes, how is this affecting you?

5. Are large amounts of money being spent on sugary or high- fat foods? If yes, how is this affecting you?

6. Do you tend to base self- worth on weight and body image?

7. Do you frequently make excuses to avoid eating or to skip meals?

8. Do you get weighed often and overreact to tiny fluctuations in weight?

9. Do you avoid social situations where food is available? If yes, how is this affecting you?

10. Have you ever hidden behaviors such as binging, purging, or laxative abuse?

Alcohol

1. Do you feel you drink more than other people? If yes, how is it affecting you?

2. Do you worry about your drinking? If yes, how is this affecting you?

3. Have you ever tried to stop drinking but been unable to do so? If yes, how is it affecting you?

4. Has your drinking ever created problem between you and a loved one? If yes, what are the problems? How are they affecting you and your relationship?

5. Have you ever gotten in trouble at work because of drinking? If yes, how is it affecting you?

6. Have you ever neglected obligations, family, or work for two or more days in a row because of drinking? If yes, how is it affecting you?

7. Have you ever been arrested or ticketed for drunk driving (DUI or DWI) or driving after drinking? If yes, how is this affecting you?

8. Have you ever missed work or important obligation because you were too hung-over? If yes, how is it affecting you?

9. Have you ever lost friends because of drinking? If yes, how is it affecting you?

10. Have you ever been hospitalized because of drinking? If yes, how is this affecting him or her? How is it affecting you?

Drugs

1. Have you ever used drugs other than those required for medical reasons? If yes, how is that affecting you?

2. Do you use drugs more than once a week? If yes, how is it affecting you?

3. Have you tried to using drugs but been unable to do so? If yes, how is it affecting you?

4. Are you worried about your drug use? If yes, how is this affecting you?

5. Has your drug abuse ever created problems between you and a loved one? If yes, what are the problems? How are they affecting you?

6. Have you lost friends because of drug use? If yes, how is this affecting him or her? How is it affecting you?

7. Have you ever neglected obligations, family, or work because of drug use? If yes, how is this affecting you?

8. Have you ever gotten in trouble at work because of drug use? If yes, how is this affecting him or her? How is it affecting you?

9. Have you ever lost a job because of drug use? If yes, how is it affecting you?

10. Have you ever engaged in illegal or dangerous activities in order to obtain drugs? If yes, how is it affecting you?

Depression / Anxiety

1. Do you often feel sad or irritable? If yes, how is this affecting you?

2. Have you lost interest in activities you once enjoyed? If yes, how is this affecting you?

3. Have you lost interest in sex? If yes, how is this affecting you?

4. Have you noticed changes in your weight or appetite? If yes, how is this affecting him or her? How is it affecting you?

5. Have your sleeping patterns changed— for example, are you having trouble falling or staying asleep, or sleeping too much? If yes, how is it affecting you?

6. Do you often have feelings of guilt, or cry easily? If yes, how is it affecting you?

7. Have you let your appearance run down— caring less about cleanliness or neatness? If yes, how is this affecting you?

8. Do you seem overly critical of things, or does your temper get out of control easily? If yes, how is this affecting you?

9. Do you often feel hopeless and worthless? If yes, how is this affecting you?

10. Have you had thoughts of ending your own life? If yes, how is this affecting you?

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